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Building on the ideas introduced in the previous TfS Dispatch—a newsletter for anyone exploring simulation for change—which described the seven Simulation-Based Intentions (SBIs) using the analogy of different lenses, this paper continues the conversation by exploring how the lens we choose shapes the way simulation is designed and used. While the earlier paper focused on understanding the purpose behind simulation activities, this paper broadens the perspective by looking beyond healthcare and considering how other safety-critical industries approach simulation. By taking this wider view, we can begin to think not only about what we simulate, but more importantly what we are designing simulation to achieve.  

In 2022, National Health Service (NHS) Forth Valley, Scotland was escalated to Level 4 under the NHS Scotland Support and Intervention Framework - triggering the highest level of oversight and engagement from the Scottish Government prior to statutory intervention. While many systems under such pressure default to compliance-driven responses, NHS Forth Valley took a different path: embracing a whole-system approach focused on leadership, culture, integration and governance. Within this, Transformative Simulation was embedded as a leadership method to support cultural and systemic renewal. A multi-professional, multi-sector delegation from the Association for Simulated Practice in Healthcare (ASPiH) visited NHS Forth Valley in early 2025 to observe simulation in practice as a leadership tool. Over two immersive days, they witnessed how simulation was used not only for education and training but also for engaging with emotionally charged challenges, enabling system-wide reflection and co-designing new models of care. Rather than retreating inward, the system opened up. One of the approaches was to progressively embed Transformative Simulation alongside a programme of culture change - not as an optional or remedial tool, but as a core leadership method for engaging with complexity, discomfort and relational repair. The framework draws on multiple fields, including human factors, patient safety science, quality improvement, implementation science, engagement theory, cultural studies and the social sciences. It is a living, practice-informed structure that honours complexity while supporting practical clarity. It enables reciprocal illumination - where multiple viewpoints surface, interact, and reshape understanding - and creates experiential foresight by allowing systems to experience change before enacting it. Over time, it builds relational infrastructure that supports trust, reflection, and sustained systems learning. Weldon SM, Mardon J, Tallentire V, et al. BMJ Leader Published Online First: [please include Day Month Year]. doi:10.1136/ leader-2025-001408.

Simulation is a well-established tool for clinical education and has been used to uncover latent safety threats (LSTs) in healthcare settings. However, the extent to which systems theory underpins efforts to detect and mitigate LSTs remains unclear. This scoping review explores how healthcare simulations have been used to identify and address LSTs, with particular attention to the visibility and application of systems theory in study design, implementation, and analysis. It concludes that simulation is a valuable method for identifying LSTs, but inconsistent application of systems theory and variable methodological transparency limit learning and generalisability. The authors suggest that future research should make theoretical underpinnings explicit, define terminology clearly, and align simulation design with both educational and organisational improvement goals.

Practice makes perfect — especially in healthcare. This podcast explores how Advocate Health and Laerdal Medical are transforming patient safety through the power of simulation. Guests Kelley Sava, associate vice president of simulation at Advocate Health, and Brian Bjoern, M.D., patient safety manager at Laerdal Medical, share how simulation-based training helps identify safety gaps, improve teamwork and communication, and prepare clinicians for life-saving scenarios before they reach the bedside.

Simulations are routinely used to identify latent safety threats. This article describes the classification of 1,318 latent safety threats identified from 232 simulations. Researchers were then able to issue site-specific and organisation-wide standardised dashboards and summaries, thus allowing for local and systemwide improvements.

Patient safety is the number one priority in health care as safety is considered at every level of a healthcare organisation (e.g., building, equipment, communication, processes for medications, treatments, and surgical procedures). Addressing the welfare of patients can be challenging, yet for some of the most vulnerable patients (e.g., special needs, disabilities and mental and social health issues), even the most routine nursing requests can put them at a safety risk. Simulations provide an opportunity for nursing students and professional nurses with realistic experiences caring for individuals with unique needs, especially when safety is a major concern.

This systematic review and meta-analysis from Mazzone et al. confirms that proficiency-based progression training in comparison to conventional or quality assured training improved trainees' performances, by decreasing procedural errors and procedural time, while increasing the number of correct steps taken when compared to standard simulation-based training.

This article, published in Simulation and Gaming proposes a strategy for ensuing simulation training following the implementation of a thorough Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS®) training initiative. The strategies include observing Teams in the workplace to facilitate the construction of organisation-wide, follow-on simulation training.

This interactive orientation of an Intensive Care Unit (ICU) bed space, created by the London Transformation and Learning Collaborative, is ideal for healthcare professionals new to the ICU environment. It allows you to explore the risks and demonstrated the safety check required to keep patients safe in the ICU. This application is best used with a smart phone, but can be used on a computer.

The COVID-19 pandemic is challenging the Canadian emergency departments (EDs) in unparalleled ways. As part of the frontline response, EDs have had to adapt to the unique clinical difficulties associated with the constant threat of COVID-19, developing protocols and pathways in the setting of limited and evolving information. In addition to the disruption of routine clinical care practices, an underlying perception of danger has resulted in a challenging clinical environment in which to make time-sensitive, high-stakes decisions. This has created an urgent need for targeted and adaptive training for all members of the emergency medicine healthcare team. The following commentary, published here by the Cambridge University Press, reflects the perspective of four emergency medicine simulation educators during the Canadian response to COVID-19.

This study, published in US journal Chest, looks at the case of a patient who experienced severe hypoglycemia due to an infusion of a higher-than-ordered insulin dose. The event could have been prevented if the insulin syringe pump was checked during the nursing shift handoff. Risk management exploration included direct observations of nursing shift handoffs, which highlighted common deficiencies in the process. This led to the development and implementation of a handoff protocol and the incorporation of handoff training into a simulation-based teamwork and communication workshop.

To address increasing patient demands and acuity, the Calgary Health Region is renovating the intensive care units (ICU) at three of their adult acute care sites. Before finalising the design plans, mock-up rooms were created at two of the sites according to several proposed room designs in order to identify potential issues during the design phase of the project. All necessary equipment was included within each of the two mock-up rooms so as to nearly replicate a functioning ICU. Evaluations of equipment, room layout and conflicts were accomplished using patient simulation of a cardiac arrest, an acutely ill patient, a palliative care patient and the admission of a new patient. Digital videos, think aloud audio tracks and extensive debriefing sessions were combined and analyzed. Specific category issues were identified including the articulating arms, visibility of the patient monitors, equipment usability, collisions with equipment, and communication issues. Elaboration of each issue and presentation of design recommendations is given.

Health Education England have produced a toolkit on human factors in healthcare looking at example of training, simulation and speaking up.

Operative vaginal birth is a common procedure used to expedite birth after full cervical dilatation where there is a clinical need to do so (15% of births in the UK in 2016). The acquisition of skills for operative vaginal birth is dependent on the exposure of junior obstetricians to situations in which they can undertake directly supervised learning. The STROBE study, published in BMC Pregnancy and Childbirth, will help establish understanding of the effectiveness of locally-delivered simulation training for operative vaginal birth. Robust evidence supporting the effectiveness of such an approach would add weight to the argument supporting regular, local training for junior obstetricians in operative vaginal birth.

Martin Bromiley, Clinical Human Factors Group, talks to Claire Cox, Critical Care Outreach Nurse and Associate Director at Patient Safety Learning.  In this podcast, Claire talks about the importance of simulation for all, using different scenarios to help raise confidence. She further describes some techniques her team are using to improve performance and safety when treating COVID-19 patients.  Claire has recently written a blog on Human factors and the ad hoc team during the pandemic for the hub.

In her latest blog, Claire, a critical care outreach nurse, reflects on how the 'ad hoc' team has to adapt to the new challenges the coronavirus pandemic brings. She offers insights into the challenges she and her team face and gives examples of potential solutions. What is an ad hoc team? An ‘ad hoc’ team is a team that is made up of various healthcare workers that have never met before. An example of this is the medical emergency team or the cardiac arrest team – doctors, anaesthetists, nurses and other allied health professionals scrambled from around the hospital expected to assess and treat a patient in crisis. Often, we don’t know each other’s names, roles or what skills we each have. What we did in Brighton is to get to know each other… We had a MET meeting every morning. We all got together and introduced ourselves, found out what skills we all had and made full use of any learning opportunities that arose. The ad hoc team worked well. We all knew what to expect, even when a complex situation arose – we all knew who to contact and how we could get the best for our patient. Then in comes a pandemic... Staff have been redeployed; rotas have been changed; the usual rhythm of the hospital has disappeared. Our regular meeting doesn’t happen. This causes problems: Who is who? What skills do people have? Has everyone been fit tested? Where do we get the PPE from during a MET call? How do we communicate to each other? What is the guidance to take blood, do an ECG, defibrillate, order an X-ray during the pandemic? All these questions and anxieties could be discussed at this meeting, but due to a change in working patterns, the change in doctors seeing different patients (Green and Red – COVID + or COVID –), its not possible to meet up. Our technical skills are not a problem – the team have great skills in advanced life support, using life saving equipment. What we are finding difficult is the non-technical skills: communicating, tone of voice, body language. It was hard enough to communicate in a high stress situation before all this pandemic… now its even harder and so much more important! Simulation Simulation has been a large part of how we train in low volume, high risk scenarios in hospital. Cardiac arrests, medical emergencies, emergency intubation, transfer, pacing… you name it we have probably simulated it here at Brighton. I have been on the medical emergency team for 9 years now. I like to think I have experience in most emergencies and know what to do and who to call. All of a sudden, I feel a novice. I don’t even know how to go into the room correctly, I don’t know what I should take in to the room, I don’t know what I should wear; every action, every protocol I would normally do can't happen due to current constraints. I am worrying so much that I feel paralysed to do anything for fear I’m doing it wrong. We have simulations every day at 3 pm at our hospital. These simulations are very low fidelity and include how a medical emergency or cardiac arrest in the COVID-19 patient should run. Simulation can never replace what a real-life scenario will feel like. What simulation can do is allow you to understand what needs to happen, in what order and lets you make mistakes in order for you to learn. Most adults learn from ‘doing’ and from experiences – I am so glad we had this simulation as I was about to attend my first MET call a few days later. My experience attending an airway medical emergency The call went out. "Medical emergency XXX ward – COVID positive". Shortly followed by "Anaesthetic emergency XXX ward- COVID positive". I ran faster knowing that as a team we all had to get there and put full PPE on before we could attend to the patient. If the patient has an airway problem, they will not be able to breathe properly and be at high risk of stopping breathing. I remembered at the simulation exercise that one person needs to be the ‘gate keeper’. I decided to take on this role as I wasn’t sure who had attended the simulation before and knew about this role. My role as gate keeper is to make a note of who is in the room, what role they have and to take messages in and out of the room from the doorway. The notes are not able to be taken into the room, so it would be the gate keeper's role to get the information across to the team inside. I was opening and closing the door and trying to hear muffled voices; I was equally trying to convey important medical information, but they couldn’t hear me well enough. It didn’t help that for many of the team English is not their first language; this made it even more difficult. Our anaesthetic team simulate situations on a regular basis as part of normal work. They turned up at the call already kitted up in PPE and wheeling a trolley with everything they needed on it; all their drugs and equipment were there. One of them – the lead anaesthetist – had a headset on which was connected to a walkie talkie. This made conversing with the team so much easier. We could ask questions from outside the room into the room and vice versa without having to open the door. Clearly, they had rehearsed this scenario before – they too couldn’t hear well so had solved the problem by obtaining walkie talkie devices. They asked for equipment, called for X-ray or asked for more information and I could either relay information, pass equipment or order tests for them – so much easier and safer. The patient had a complex airway and needed to be seen by a specialist. A consultant arrived; one I had not met before. He arrived anxious. He was worried about donning the PPE in the correct order and in swift time. I helped him donn and, while I did that, I reassured him on who was in the room, what had happened and what treatment the patient had had. He entered the room knowing he had the right gear on and what he was facing. This enabled him to think clearly and treat the patient. When it was time to transfer the patient to intensive care, we came across a problem. We had two differing protocols. One was from yesterday, the other was rewritten this morning… which was correct? This was quickly cleared up by calling the author of the protocol, but what would happen at 3 am if this was to happen again? Reflections It was my first time as gate keeper. To be honest, I didn’t know what I should be doing… some of the information from the simulation flew from my mind. Looking back, I should have asked for the name and role of who walked into the room and wrote it on their PPE or used stickers. People were in such a rush to get in and save the patient's life that it didn’t feel like a priority at the time. The walkie talkies were a genius idea from the anaesthetists – this is something that I will take back and see if we can implement the same for all MET calls (anaesthetists do not attend MET calls normally). It reduced the opening and closing of the door, which reduced the amount of aerosoled particles to come out from the room that may increase risk of infection to others. Flattened hierarchy – the moment I had with the consultant outside that room was something I hadn’t experienced before. I noticed his vulnerability, he looked for me – a nurse – for reassurance and guidance which was given with no judgement. At that moment we knew we were one team. Protocols keep changing. We are working where national guidance and local policy changes daily. Without robust ways of disseminating this information we run the risk of doing the wrong thing. As clinicians we are not at our desks monitoring for changes in guidance – we need ways of getting this information to us. We use the ‘workplace’ app – we have a ‘microguide’ for all our up to date policies. This is great to use in normal circumstances but when dressed in PPE we are not always able to access our mobile phones. I wasn’t inside the room. I could see the patient. I could see that he was scared. He couldn’t breathe, he was unable to talk anyway due to his altered airway. How were the team communicating with him? How was he being reassured? Our facial expressions say a thousand words – behind a mask the patient sees nothing. I have heard of the CARDMEDIC flash cards, but can we use them in an emergency? Perhaps we could add them on to the cardiac arrest trolley? The patient is doing well on intensive care now. It would have been ideal for us to debrief; however, half the team go with the patient the other half of the team need to get back to other sick patients, so this can't happen. So much learning comes from these calls; we haven’t got this bit right yet.